Form MO580-3009 "Dental Application for a Controlled Substances Registration and Practitioner Availability Census" - Missouri

Form MO580-3009 is a Missouri Department of Health and Senior Services form also known as the "Dental Application For A Controlled Substances Registration And Practitioner Availability Census". The latest edition of the form was released in August 1, 2017 and is available for digital filing.

Download an up-to-date Form MO580-3009 in PDF-format down below or look it up on the Missouri Department of Health and Senior Services Forms website.

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Download Form MO580-3009 "Dental Application for a Controlled Substances Registration and Practitioner Availability Census" - Missouri

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Missouri Department of Health and Senior Services
P.O. Box 570, Jefferson City, MO 65102-0570      Phone: 573-751-6400
FAX: 573-751-6010
RELAy MiSSOURi for Hearing and Speech impaired 1-800-735-2966
vOiCE: 1-800-735-2466
Dear Applicant:
Attached is an application and instructions to complete an application for a Missouri Controlled Substances Registration. Please review
the instructions before completing and submitting the application.
General Information For All Applications:
(1) No controlled substance activities may take place until an application has been processed and a registration has been issued.
There are no renewals. All registrations have an expiration date or may terminate under certain conditions. No controlled
substance activities may take place until a new registration has been issued. Only the doctor may complete the application and
it cannot be delegated.
(2) A state registration from the Bureau of Narcotics and Dangerous Drugs is required prior to applying for a federal registration from
the United States Drug Enforcement Administration. Controlled substance activities may begin once both registrations are in
place. LTCFs are not required to have DEA numbers. The addresses on state and federal registrations must match.
(3) Pursuant to state regulations, all fees are processing fees and are not refundable.
(4) Checks should be made payable to the Missouri Department of Health and Senior Services.
(5) Applications and fees are processed through the department’s fee receipt unit before being forwarded to the Bureau of Narcotics
and Dangerous Drugs for processing and issuing registrations. Applications go to the Fee Receipt Unit before being forwarded
to the BNDD.
(6) The bureau no longer prints and mails controlled substance registration certificates. The verifying and printing of registration
certificates can be accomplished at the bureau’s website www.health.mo.gov/BNDD.
(7) Please review your application for completeness and accuracy before submitting it to the department. Errors and omissions
cause delays in processing applications. Please insure printing is legible.
(8) All applications submitted on paper must be mailed to the department’s Fee Receipt Unit at the following addresses:
Fee Receipt Unit
Hand delivery address is:
P.O. Box 570
920 Wildwood Drive
Jefferson City, MO 65102-0570
Jefferson City, MO 65109
Bureau of Narcotics and Dangerous Drugs
P.O. Box 570
Jefferson City, MO 65102-0570
Phone: (573) 751-6321 Fax: (573) 526-2569
Website www.health.mo.gov/BNDD
www.health.mo.gov
Healthy Missourians for life.
The Missouri Department of Health and Senior Services will be the leader in promoting, protecting and partnering for health.
AN EqUAL OPPORTUNiTy/AFFiRMATivE ACTiON EMPLOyER: Services provided on a nondiscriminatory basis.
MO 580-3009 (8-17)
Missouri Department of Health and Senior Services
P.O. Box 570, Jefferson City, MO 65102-0570      Phone: 573-751-6400
FAX: 573-751-6010
RELAy MiSSOURi for Hearing and Speech impaired 1-800-735-2966
vOiCE: 1-800-735-2466
Dear Applicant:
Attached is an application and instructions to complete an application for a Missouri Controlled Substances Registration. Please review
the instructions before completing and submitting the application.
General Information For All Applications:
(1) No controlled substance activities may take place until an application has been processed and a registration has been issued.
There are no renewals. All registrations have an expiration date or may terminate under certain conditions. No controlled
substance activities may take place until a new registration has been issued. Only the doctor may complete the application and
it cannot be delegated.
(2) A state registration from the Bureau of Narcotics and Dangerous Drugs is required prior to applying for a federal registration from
the United States Drug Enforcement Administration. Controlled substance activities may begin once both registrations are in
place. LTCFs are not required to have DEA numbers. The addresses on state and federal registrations must match.
(3) Pursuant to state regulations, all fees are processing fees and are not refundable.
(4) Checks should be made payable to the Missouri Department of Health and Senior Services.
(5) Applications and fees are processed through the department’s fee receipt unit before being forwarded to the Bureau of Narcotics
and Dangerous Drugs for processing and issuing registrations. Applications go to the Fee Receipt Unit before being forwarded
to the BNDD.
(6) The bureau no longer prints and mails controlled substance registration certificates. The verifying and printing of registration
certificates can be accomplished at the bureau’s website www.health.mo.gov/BNDD.
(7) Please review your application for completeness and accuracy before submitting it to the department. Errors and omissions
cause delays in processing applications. Please insure printing is legible.
(8) All applications submitted on paper must be mailed to the department’s Fee Receipt Unit at the following addresses:
Fee Receipt Unit
Hand delivery address is:
P.O. Box 570
920 Wildwood Drive
Jefferson City, MO 65102-0570
Jefferson City, MO 65109
Bureau of Narcotics and Dangerous Drugs
P.O. Box 570
Jefferson City, MO 65102-0570
Phone: (573) 751-6321 Fax: (573) 526-2569
Website www.health.mo.gov/BNDD
www.health.mo.gov
Healthy Missourians for life.
The Missouri Department of Health and Senior Services will be the leader in promoting, protecting and partnering for health.
AN EqUAL OPPORTUNiTy/AFFiRMATivE ACTiON EMPLOyER: Services provided on a nondiscriminatory basis.
MO 580-3009 (8-17)
INSTRUCTIONS FOR COMPLETING DENTAL APPLICATION
Please review these instructions and instructional fields as the application is completed to insure all fields are completed correctly with
the required information. incomplete applications cause delays in processing.
Fields on the application that are required to obtain a controlled substances registration are marked with an asterisk(*). There are other
questions on the application that are voluntary for the purposes of taking a census to determine practitioner availability and shortage
areas in Missouri.
(1)* indicate if this is your first registration ever, or if you have been registered in Missouri before. All registrations are new and there
are no renewals.
(2)* A social security number is required pursuant to Section 454.403, RSMo. Applicants must also submit their date of birth
MM/DD/yyyy.
(3)* Please indicate if you are licensed as a DDS or DMD, or if your state license is currently pending. Licenses are not required for
dental students enrolled in an authorized dental school.
(4)* Please provide your full legal name, along with your gender, race, and ethnicity.
(5)
Please indicate what languages you fluently speak.
(6)
Please provide your current email address where the bureau may contact you or send information.
(7)* Please provide information pertaining to board certifications.
(8)* Please check the box to indicate your primary specialty.
(9)* Please provide your current DEA controlled substance registration number if you have one. if you do not have one, you may enter
the word “pending.”
(10)* Please indicate what drug schedules you are requesting authority in. A complete list may be viewed at the bureau’s website,
www.health.mo.gov/BNDD under the link to publications.
(11)* Please indicate what your anticipated drug activity will be at this primary practice location.
(12)* Please provide your principle and primary practice location where this registration may be issued. This must be a Missouri practice
location where patient care occurs and controlled substance activities take place. it must be a physical street address and not a
PO Box or mailing address. This should be the primary location of where the practitioner spends the most time. This principle
address is what appears on the drug registration certificate. it must match the federal DEA certificate address. Please provide
the business telephone number and fax machine number for this location.
(13) Please check the box to indicate the practice setting type and any types of obligations you have at this location. Please answer
questions for the census for services offered at a reduced rate, acceptance of Medicaid, if new patients are being accepted, and
chair-side hours per week you work as well as hours for dental assistants and dental hygienists.
(14)* if you have secondary and multiple practice locations, you must attach a listing of these addresses as described in field #12 above.
The secondary addresses are required. We ask that you would also voluntarily submit the census questions in field #13 for these
secondary locations. These secondary locations would be where you prescribe only. if you stock and administer controlled drugs
from other secondary locations, each of those must have their own separate registration.
(15)* Please provide a separate mailing address if you would like mail sent to an address other than your practice location.
(16)* Pleased provide information on any guilty pleas entered for any controlled drug violations, regardless of what sentence was finally
imposed. This includes guilty pleas and suspended sentences. Please indicate whether this information is already on file with
the bureau. if a waiver is required, the employer must obtain a waiver before allowing an employee with guilty pleas or convictions
access to their controlled drugs.
(17)* Please provide information on any public disciplines, restrictions, probations, surrenders, or revocations taken by administrative
regulatory agencies on either your professional license or your state or federal controlled substance registrations. Please indicate
if any such regulatory discipline is in process or pending.
(18)* Section 195.040.2, RSMo states that no registration may be issued to any person who is abusing controlled substances. Please
indicate whether the applicant is abusing or has abused or been treated for or diagnosed with addiction regarding controlled
substances during the past year. For purposes of this subsection, “abusing” or “abused” means using or having used a controlled
substance in a manner not authorized under Chapter 195, RSMo.
(19)* This field provides instructions on what fees must be paid and how to pay the fees. The annual fee is $30 dollars for a one-year
registration. An additional late fee of $10 is required if the practitioner has expired and lapsed in registration for a period greater
than 15 calendar days. No fee is required if the practitioner is employed by a government agency. The applicant claiming
exemption must name the government agency. This free registration is restricted to the registrant’s government work only. if the
registrant wants to practice in the private sector the registrant must pay a fee for a registration.
(20) This field provides information on how paper applications are to be mailed or delivered to the department.
(21)* Applicants are required to physically and manually sign and date an application that is submitted on paper.
MO 580-3009 (8-17)
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MiSSOURi DEPARTMENT OF HEALTH AND SENiOR SERviCES
BUREAU OF NARCOTiCS AND DANGEROUS DRUGS
DENTAL APPLICATION FOR A CONTROLLED SUBSTANCES REGISTRATION
AND PRACTITIONER AVAILABILITY CENSUS
PLEASE USE THE ATTACHED INSTRUCTIONS THAT APPEAR AT THE END OF THIS FORM.
* IS REQUIRED FIELD
*1.
PREviOUS BNDD# iF yOU HAvE BEEN PREviOUSLy REGiSTERED
First Time Registration
*2. SOCiAL SECURiTy NUMBER (REqUiRED By 454.403, RSMO)
*DATE OF BiRTH (MM/DD/yyyy)
*3. TYPE OF BUSINESS ACTIVITY – PRACTITIONER
PROFESSiONAL LiCENSE NUMBER
NPi NUMBER
or
License is pending
OTHER STATES yOU ARE LiCENSED iN
DDS 
DMD 
DENTAL STUDENT
*4. LAST NAME
FiRST NAME
MiDDLE NAME
SUFFiX
*GENDER
Male 
Female
*RACE (CHECk ONE)
Caucasian
African-American
Asian indian
American indian
Alaskan Native
Chinese
Filipino
Guamanian
Chamorro
Japanese
korean
Native Hawaiian
Other Asian
Other Pacific islander
Samoan
Multiracial/Other
*ETHNiCiTy (CHECk ONE)
Cuban
Mexican
Mexican-American
Chicano
Non-Hispanic
Other Non-Hispanic/Latino
Spanish
Puerto Rican
5. FLUENT LANGUAGES (MAy CHECk MULTiPLE)
English
Spanish or Spanish Creole
German
French (incl. Patois & Cajun)
Chinese
vietnamese
Serbo-Croatian
italian
Russian
Arabic
korean
Tagalog
African Languages
Other West Germanic
*7. CERTIFICATION
6. EMAiL ADDRESS
Board certified 
Board eligible
Not applicable
*8. PRIMARY SPECIALTY
*9. DEA NUMBER IF YOU HAVE ONE
Endodontist
General Practice
Oral Pathologist
Oral Surgeon
Orthodontist
Pedodontist
Periodontist
Prosthodontist
*10. CONTROLLED SUBSTANCE SCHEDULES REQUESTED
Schedule ii — (opiates, morphine, oxycodone, meperidine)
Schedule iii — (acetaminophen w/codeine)
Schedule iv — (benzodiazepines, alprazolam, diazepam, ativan)
Schedule v — (diphenoxylate)
MO 580-3009 (8-17)
AN EqUAL OPPORTUNiTy/AFFiRMATivE ACTiON EMPLOyER
PAGE 1
Services provided on a nondiscriminatory basis
*11. ANTICIPATED DRUG ACTIVITY
Prescribe only — no stock on site 
Prescribe, stock, dispense, and administer controlled drugs on site
*12. PRIMARY PRACTICE LOCATION (Must be a physical Missouri address where patient care occurs and controlled drug activity takes
place. This must be your principle location where you spend the most time.)
STREET ADDRESS
CiTy
STATE
ziP CODE
COUNTy
BUSiNESS PHONE NUMBER
BUSiNESS FAX NUMBER
13. PRACTICE SETTING TYPE
Community Health Center
Correctional Facility
Dental School
Free Clinic
Hospital
Military facility or other federal facility
Mobile Dentistry
Nursing Home/LTCF
Other State Facility
Private Office
Public Health
OBLiGATiON TyPES
J-1 viSA
National Health Service Corps
National interest Waiver
None
State Loan Repayment
DO yOU PERFORM SERviCES AT A REDUCED RATE, USiNG A SLiDiNG FEE SCALE, FOR iNDiviDUALS WiTH qUALiFyiNG iNCOMES?
yes     
No
DO yOU ACCEPT MEDiCAiD?
DO yOU ACCEPT NEW PATiENTS?
yes     
No
yes     
No
*ENTER THE NUMBER OF CHAiR SiDE HOURS PER WEEk yOU WORk
EXCLUDiNG DENTAL HyGiENiSTS, HOW MANy DENTAL ASSiSTANTS DO yOU
AT THiS LOCATiON
EMPLOy AT THiS LOCATiON?
PER WEEk
*ENTER THE TOTAL NUMBER OF CHAiR SiDE HOURS PER WEEk THE ABOvE ASSiSTANTS WORk AT THiS LOCATiON
PER WEEk
NAMES OF HyGiENiSTS AT THiS LOCATiON AND THEiR CHAiR SiDE HOURS PER WEEk AT THiS LOCATiON
*14. If you have secondary practice locations, please submit the information for Sections 12 & 13 above for each additional location.
you have now completed Sections 12 & 13 that describes your primary practice location. your controlled drug registration must be at
your principle practice location where you spend the most time. if you have a secondary or additional practice locations, please complete
the questions for Section 10 above and provide that additional information with your application for the secondary locations.
MO 580-3009 (8-17)
PAGE 2
*15. MAILING ADDRESS (If you would like your mail sent to a separate address other than practice location)
STREET ADDRESS
TELEPHONE NUMBER
CiTy
STATE
ziP CODE
*16. CRIMINAL HISTORY INFORMATION
This question pertains to not only criminal convictions, but also any pleas of guilty, no contest, nolo contendere, or cases where probation
was received, even if convictions were later removed. This applies to any guilty pleas for any drug offenses regardless of the final sentence
or outcome.
Has the applicant or any employees of the applicant who have access to controlled substances, ever pled guilty, nolo contendere, no contest,
or otherwise ever been convicted of any violation of any state or federal law relating to controlled substances?
yes     
No
if yes, a copy of the conviction information must be on file with the bureau. Has the information been previously submitted?
No      If no, please provide the required information with this application.
yes     
if the applicant answered yes to the questions regarding convictions or guilty pleas, a waiver must be obtained before an employee can have
access to any controlled substances. A waiver may be applied for at the bureau’s website www.health.mo.gov/BNDD under the link to
applications and forms. There is an application for a waiver. Has the employer already obtained a waiver for the employee at this practice
location?
yes     
No
*17. ADMINISTRATIVE LICENSURE AND REGISTRATION DISCIPLINE HISTORY
Have any of the applicant’s state professional licenses, or state or federal controlled substances registrations, ever been revoked,
surrendered, suspended, restricted, or placed on probation — or has any application for a professional license or a state or federal controlled
substances registration ever been denied?
yes     
No
if you answered yes, please attach a copy of the discipline.       
Already on file with the BNDD
Although a disciplinary action may not be finalized, is such an action pending?
yes     
No
These questions apply to administrative and regulatory discipline for licenses and registrations. This question is not for criminal convictions.
18. UNAUTHORIZED USE/ABUSE OF CONTROLLED SUBSTANCES
Unauthorized use and abuse of controlled substances is defined by the bureau as possessing, self-administering or ingesting a controlled
substance that was not legally obtained, possessed or authorized by a legitimate medical practitioner acting within the scope of professional
practice. All activities with controlled substances must be authorized by Chapter 195, RSMo.
During the past year, have you abused any amount of a controlled substance not authorized by law?
yes     
No        (This would be controlled drugs not legally obtained or legally prescribed)
During the past year, have you been diagnosed with or received any treatment for chemical dependency or addiction relating to controlled
substances?
yes     
No
*19. PAYMENT OF FEES
The annual fee is $30 dollars for a one-year registration. These are processing fees and are not refundable. The fee must accompany the
application. Fees may be paid by personal or certified check, cashier’s check or money order. Checks should be made payable to the Missouri
Department of Health and Senior Services. you are exempt from paying fees if you are employed by a government agency. Having a fee
exempted registration restricts your practice to only the government location. if you practice with controlled substances at a non-government
location, you must obtain a separate registration and pay the appropriate fee.
Are you employed by a government agency and exempt from fees?
yes     
No
if yes, please provide the name of the government agency: _______________________________________________________________
if your former registration has expired more than 15 days, an additional $10 late fee is required.
MO 580-3009 (8-17)
PAGE 3
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